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This information is provided for educational purposes only. References to commercial products or trade names is made with the understanding that no discrimination is intended and no endorsement by Cornell Cooperative Extension is implied.

Extension Association Information Form
Volunteer Applicant: So we are able to match your skills and talents with the volunteer opening best suited for you, we need to get to know you better. Please complete all parts of this form and return it to our office at 615 Willow Avenue, Ithaca, NY 14850. Thank you.
General Information
Name
Last 		First Middle Today's Date
Address
Street 		City State Zip
Phone Number
Daytime 		Evening Email Address
Do you possess a valid NYS driver’s license? Yes No  
Have you ever been convicted of a crime? Yes No If so, please explain.
A criminal conviction will be considered only in relation to the position for which you are applying. Seriousness and nature of the offense, time elapsed, and rehabilitation will be taken into account.
Volunteer Position
Position(s) of Interest (If not sure, leave blank)
 Audience age level preference
Dates, days, and times available
 Time commitment desired
Where did you learn about this opportunity?
 
Volunteer/Employed Experience
Organization/Employer
 Position Title/Major Responsibility
 From mo/yr to mo/yr
Other Relevant Experience
Describe any relevant education or training you have had which you feel is related to the position for which you are interested. Also describe any special educational skills, experiences or interests along with organizations, honors, certifications, licenses, publications etc. you consider relevant.
References
List at least two persons, other than relatives, who are familiar with your character and have knowledge of your qualifications.  
Name
 Title
 Mailing Address
 Telephone
home:
work:
home:
work:
home:
work:

I hereby affirm that the statements made on this application are true. I understand that misrepresentation or omission of facts requested is cause for non-appointment as a Cornell Cooperative Extension volunteer. I authorize Cornell Cooperative Extension of Tompkins County to contact listed references and employers and understand that references contacted will not necessarily be limited to those indicated on this form. If appointed as a volunteer, I agree to adhere to the general policies and guidelines set forth by Cornell Cooperative Extension of Tompkins County and to fulfill my assigned volunteer responsibilities to the best of my ability. I realize that this is a non-paid volunteer position.
Date:

Cornell University : Cornell Cooperative Extension : Tompkins County :Publications : Volunteer Application
Address: 615 Willow Ave; Phone: 607-272-2292; FAX: 607-272-7088; Email: tompkins@cornell.edu

Last Updated: January 22, 2008
Contact: tompkins@cornell.edu